Archive for the ‘Miscellaneous’ category

“There should be a law”: One Patient Pays $ 13,245.85 in Drug Dispensing Fees

June 11, 2014

I work in an addiction treatment clinic. Some days I think there is little that would shock me, but then there is always the pharmacy industry.

Recently we had a patient transfer to our clinic. Unlike most of our patients he was a “private pay” patient with insurance. Also, unlike most of our patients he was taking a new drug, buprenorphine, or suboxone, to help treat his addiction.

We continued his drug treatment and found him a pharmacy close to his home in a small town near Kingston. A couple of days after starting treatment he called to see if there was anything we could do about his dispensing fees. He was going broke paying for his medication.

A call to the pharmacy established that he was paying $26.31 a day of his own money in dispensing fees for the one drug.  On top of that the pharmacy was collecting a further $9.98 from the insurance company for a total income to the pharmacy of $36.29 per day. The cost of the drug is paid separately to the pharmacy and covered by insurance.

Put a bit more grossly, the pharmacy was collecting $13,245.85 a year to dispense this one drug to one patient. Think about the member of patients and number of prescriptions and this is an even more jaw-dropping figure: but one backed up by patient receipts and phone call discussion with the pharmacy.

For the patient, 26.31 dollars a day is nine thousand six hundred and three dollars a year to treat his addiction. Even if he was working, which he is not, this would be completely untenable, precluding any possibility of treatment.

With this one example it is easy to see how pharmacies, not just big pharmaceutical manufacturers, are “cash cows” lusted after by large corporate conglomerates. Indeed most community drugs in Ontario are dispensed by large chain pharmacies and we increasingly use these for-profit corporations to provide more essential health services, such as, immunizations and prescription renewals.

How is this barrier to access for a medical treatment permitted in our health care system? The pharmacy in question is a Shoppers Drug Mart; part of chain currently owned by the multibillion dollar corporation, Loblaw. Maybe it is time to put pharmacists on salary and prohibit large corporate ownership of pharmacies, or, simply have all medications dispensed from public non-profit community pharmacies building on the expertise and supply chain already available in our hospital system.

Failing these solutions, this person’s troubles accessing needed drugs is a strong argument for a universal pharmacare program.

Canada Health Act used in Zombie Defence of For-Profit Health Care

October 14, 2012

Andrew Duffy, in an article syndicated by Postmedia, made the logical equivalent of mixing metaphors when he used the Canada Health Act (CHA) to legitimize the use of private clinics. The result, as with mixed metaphors, is a “head-scratching” argument in favour of Centric’s takeover of the Shouldice Clinic.

Duffy uses a confidential government manual found by Jeffery Simpson, author of a recent book on Canada’s health care system, to argue that the CHA was not intended to prohibit the use of for-profit companies to deliver essential medical services.  This expose, complete with grainy pictures, is used to undermine what Duffy sees as a key argument of most who oppose private health care.

Unfortunately for Duffy he is not addressing those who oppose for-profit medicine nor is Jeffery Simpson’s revelation a revelation.  The existence of the manual is an interesting historical footnote but it is only necessary to read the widely distributed Romanow discussion papers to know that the CHA does not prohibit the use of for-profit companies.  As Duffy points out the CHA has been used to penalize provinces for extra billing and user fees, not for using private companies to deliver publicly funded services.

Duffy then mixes his political facts to imply that the opposition to the takeover the Shouldice Clinic by the health care conglomerate, Centric, is based in some misunderstanding of the Canada Health Act.  This is confusing. He has apparently read our letter to Ontario’s Minister of Health objecting to the takeover and it only mentions the CHA in the context that many for-profit companies extra bill, charge user fees, and allow patients to queue jump: all illegal. Duffy seems to think that because the CHA, as all pieces of legislation, is a compromise between different social forces and does not ban private companies, that it condones their use? Andrew, while we are scratching our heads, a quick trip to a logic 101 class might help.

The sale of Shouldice to Centric once again raises the issue of how best to deliver health care. Along with the well researched and documented concerns of increased cost and mortality and decreased quality and access associated with for-profit providers, which have been outlined in this blog and many other more reputable sources, Centric highlights the growing problem of corporate concentration and foreign ties in Canada’s private health care sector.

Centric is nominally a Canadian company but it has strong ties to transnational private equity firms. For-profit primary care chains, such as Appletree, AIM and MCI, are expanding their presence; laboratories and other diagnostic services have for decades been dominated by an oligopoly of multinational corporations; and Saskatchewan’s expansion into publicly paid for-profit surgery uses Surgical Centers Incorporated, a chain with facilities in Alberta and British Columbia.

Do these conglomerate chains increase the problems of for-profit care? Do they open Canada to trade challenges undermining public health care?  Do they place Canadian health care needs below foreign profit concerns?  All good questions which are hard to answer because we do not even have access to simple accountability data like, how much public money is paid to these for-profit companies?

There are problems with the CHA: one is that it does not require public non-profit delivery.

A problem with the health-care-delivery debate is that those who favour the use of for-profit companies tend to rely on fabricated arguments, for example, ‘activists oppose private delivery because they misunderstand the Canada Health Act.’  These fabricated arguments, like all other zombies, are hard to kill because their perpetrators won’t come into the daylight and address the real problems with for-profit delivery.

Duffy’s article can be found at: http://www.canada.com/health/Cabinet+document+shows+Canada+Health+open+private+clinics/7383633/story.html

Medical Journal Kills For-Profit Lab Debate

May 7, 2012

I was surprised when the Canadian Medical Association Journal (CMAJ) asked me to write an analysis piece on Canada’s medical laboratories. My book, False Positive, clearly lays out my position that for-profit labs have no place in our health care system, which is at odds with the close, and profitable, relationship between the labs and many doctors. And I am a well-known critic of private health care delivery in general, a policy option that many doctors organizations have not supported.

Regardless, I was interested because an article in the CMAJ would reach a different audience than I had already reached with the book and spin-off speeches and articles. The CMAJ also wanted an international component. I know little about international laboratory services and was interested in learning. So I spent the summer investigating lab services in the United Kingdom and Australia.

When I submitted my first draft the editor said there was too much international content and what they really wanted was a focus onCanada’s services. Oh well, information and perspective gained, and the rewrite was easy, after all most of the data came from my own research.

The next draft was accepted for peer review. Two of the three reviews came back quite positive including comments such as, “a well written and researched paper. The results are interesting and worth disseminating.” The third reviewer felt that the article was too biased against for-profit labs, but provided nothing to refute the core evidence. A third draft was submitted based on the comments of the three reviewers.

So far the process had been fairly normal, but now it moved into the unusual. My rewrite, which met many of the concerns of the reviewers, was now deemed to be too biased by the editors but good enough to print as long as an article in favour of the private labs was included as well. They felt a need for balance. Again, they did not dispute the claims made in the article, including facts that have been used to support for-profit laboratories, only its perspective.

If the CMAJ is suggesting that to be publishable articles must incorporate more than one perspective almost none would be published. The research and analysis must be rigorous and defensible on peer review, criteria the article seemed to have met. The editors suggested, I guess to try and preserve some sense of integrity, that they would solicit another article supporting private labs and print both articles.

While I thought this was strange, I had no objection and agreed to this approach. Three months later I received a letter stating that the editors had, “not been able to attract the appropriate author to write [a paper in favour of private laboratories],” so my article was rejected. My first thought was that maybe they could not find an appropriate, I assume academic, author because there is a lack of credible evidence supporting the use of private labs. Those involved in the private laboratory industry would also not have agreed to engage in the debate because they prefer to “fly below the radar.” This is a political strategy that has been very profitable for them and it is a shame that the CMAJ would enable this lack of accountability.

As well as the organized medical profession’s intimate relationship with the private medical laboratories in four provinces the Canadian Medical Association (CMA) has been accused of trying to influence the CMAJ’s editorial policy. Five years ago the CMA relationship with the CMAJ came under intense international scrutiny after the firing of editors and resignations from the editorial board following allegations to this effect. Both the very unusual path my article took and the CMAJ’s history again call into question the journal’s independence.

My position that for-profit corporations should not be involved in the delivery of publicly funded health care is controversial but not unreasonable. It is defensible, has strong factual support and is part of an important debate on the future of our health care system. It is unfortunate if the CMAJ lets fears about upsetting the private interests of sections of the medical community override its mandate to present solid information and discussion on health care policy.

Legal Abstractions and For-Profit Delivery

April 18, 2012

The categories we use to make sense of the world structure how we act.

In his April 17th column Andre Picard, the health reporter for Toronto’s Globe and Mail newspaper, repeated one the most misleading justifications for more for-profit health care: most of the system is already private.  After all, as Picard points out, many family physicians are self-employed and almost all hospitals are private, albeit non-profit, corporations.  To equate public hospitals and family physicians with for-profit corporations, like Gamma-Dynacare, the Gambie Surgical Center, and the AIM Health Group, is to bury your head in legalistic sand. The result is Picard’s implicit support for the Wildrose’s health policy, one of the most pro-corporate in Canada.

Sure hospitals are not public in the sense of directly part of the public sector, but that is how people see them: as part of the public system.  More important, that is how they are treated by governments. The wide spread use of regional health authorities, regulations on transparency, wait time goals, inclusion in Freedom of Information and Sunshine laws and directives on what services hospitals can provide, are among a plethora of ways hospitals are treated as a part of the public sector.

For-profit corporations are treated differently and act differently. Freedom of Information laws protection their business confidentiality so we do not have the same access to quality measures, how the public money we pay them is spent, or information on investment decisions. Private corporations are allowed to lobby to protect and expand their interests.  These interests include finding more income opportunities either by removing health care from public coverage so that there is more private payment, or increasing the number of procedures and fee-for-service payments they receive from public insurance.  Both of these are often opposed to the public interest yet these companies are allowed to use public money to lobby for their own interest against the public interest.

For-profit companies also use their profits to pay shareholders and reinvest as they see fit, often in more private health care.  Money saved in the public system is returned to the public coffers. There is also a higher rate of fraud among private, for-profit corporations.  In the United States over four billion dollars was collected in fines for health care fraud in 2011.

When all is said and done the use of for-profit companies within public health care is not similar to using public non-profit providers, no matter how much regulation we have.  To say they are all private is to confuse profit making with public interest and encourage more private profit taken out of health care dollars for no benefit.

Instead of using legalistic abstractions which see a more privatized system it would be more helpful to use the real world experience of patients and health care providers. Currently about 70% of our system is publicly financed, lower than most other developed nations.  We could start by increasing the number of services that are publicly covered.

The vast majority of our essential medical services, laboratory and diagnostic services being the notable exceptions, are delivered by public, non-profit institutions. Many doctors, while legally small business people, essentially pay themselves a salary and work primarily for the benefit of their patients. The trend we need to be concerned about is the increased use of for-profit corporate chains providing primary care.  These often rip-off doctors and ill serve their patients.  The growing use of these corporate clinics is a development we see more clearly when a key dividing line in health care delivery is between for-profit corporations and a variety of public and non-profit providers.  This is a distinction that serves us better in improving health care than abstract legalisms.

The link to Andre Picard’s article is http://www.theglobeandmail.com/life/health/new-health/andre-picard/firestorm-over-wildroses-health-care-policy-pits-myths-against-reality/article2404555/?utm_medium=Feeds%3A%20RSS%2FAtom&utm_source=Life&utm_content=2404555

Public Insurance vs. Private Delivery

July 8, 2011

The magazine Lab  Business did an interview on False Positive and the value of public labs.  A transcript of the interview can be found  at:

http://www.labbusinessmag.com/articles/2011mjpubliclabs/publiclabs.html

A theme in the interview  was the relationship between public delivery and universal health insurance  system. The interview drew out the fact that with a single payer system public delivery is the most cost-effective. If cost is a concern, and it should be,  than universal insurance requires public delivery.

The corollary of the incompatibility  between public insurance and private delivery is that private delivery will  undermine universal insurance and likely lead to its demise. For-profit delivery of publicly paid health care services increases cost which either increases  taxes but not service or decreases service: neither are desirable.  As the public system becomes less accessible and costs increase there is pressure from those that can pay to buy more dependable private health care.  Private companies welcome this business. They can charge more and increase their profits while using public payments as the mainstay of their income.  As more people buy privately, the clamor for broader private insurance coverage and limiting universal insurance increases.  These dynamics have all been active in provinces where for-profit corporations deliver public laboratory services.

A cynic might say that supporters of private delivery, even though they argue that it will improve public health care, are pushing these alternative delivery options as a way of eventually opening up the market to more private insurance.  On the other hand this cynic might simply be an accurate observer of Canadian health care politics. The overwhelming public support for medicare, and its acknowledged benefits in terms of cost, access and justice, makes it a hard political target.  But advocating private delivery is less risky and, if they succeed, private delivery can make public insurance unstable and eventually unpalatable as a universal system.

Sustainability Alliance Sustains Private Interests

May 18, 2011

The Conference Board of Canada recently launched the Canadian Alliance for Sustainable Health Care, another think-tank, funded by the wealthy and healthy, whose purpose is to produce evidence-based approaches to the reform of medicare. This alliance joins a growing number of interest groups that claim to be looking for “alternative” health care delivery solutions — in other words, solutions that involve the use of more private companies. What these groups don’t seem to understand, or maybe prefer not to consider, is that there is significant evidence out there that using private companies to deliver publicly funded health care costs the Canadian taxpayer more money, not less. This is certainly the evidence from our forty-year case study using for-profit private laboratories to provide an essential medical service: not only are they more expensive, they work against health care integration and negatively impact access and quality for patients.

But it is not only laboratories.  Some of the most extensive studies comparing the use of for-profit companies to deliver health care vs. non-profit organizations comes from McMaster University and show that private corporations in the United States increase costs and increase deaths.  Other research in Canada has shown increased cost in building and operating hospitals when private companies are involved and  increased cost and loss of access to surgeries, home care and diagnostic services when the market and private companies dominate.

Rather than trying to square a circle this research money would be more profitably spent, pardon the pun, if it was used to bring private services, like labs, back into the public non-profit system and improve the sustainability, accessibility, quality and democracy of public non-profit delivery.  The main problem with this approach is that the public would benefit and less money would be made by private investors. This is a problem most Canadians could live with.

Bad Blood

April 29, 2011

The following are excerpts from news coverage in the Wellington Times, http:\\wellingtontimes.ca, in an article titled Bad Blood.   Thank you to Rick Conroy for interesting coverage of my presentation. The only comment I would add is that prior to medicare many needed tests were not ordered because the patient could not pay for them.

…”Make a fist and let go,” says the phlebotomist, “this won’t hurt a bit.”With these words thousands of lab technicians draw blood for a variety of medical tests each and every day in Ontario.

For Ross Sutherland, the big business of community labs is serving people poorly and robbing the health care system of precious resources. More worrisome, he says, private lab corporations offer a warning of what happens when universal health care and the single-payer system is mixed with for-profit organizations…

He spoke to the final gathering of the Friends of Health Care in Prince Edward County last Thursday. He noted the challenges this community has endured with lineups, short hours and general indifference demonstrated by MDS, and now LifeLabs, at the blood and specimen collection facility at the medical clinic in Picton.

Sutherland traces the problem back to the inception of Medicare with the introduction of the single payer. Until then, family doctors paid for blood and specimen tests and passed these costs on to their patients. Doctors were careful to order only the tests that seemed necessary, to manage costs for themselves and their patients…

But with the introduction of the single payer—universal health care in the 1960s—this constraint was removed. Doctors could order as many tests as they wanted. The small community labs suddenly became quite lucrative. As the sector grew, a wave of consolidation reduced hundreds of firms to just a handful; today three firms—Life Labs, Gamma-Dyancare and CML Healthcare control more than 90 per cent of the commercial lab business in Ontario…

In response to the changed landscape, many of these hospital labs formed non-profit community lab services facilities to better use their facilities and provide an additional revenue stream to the hospitals…

The province decided that Hospital In-Common Laboratories (HICL), as hospital-based community lab services were known, would be reimbursed at 75 per cent of the rate of private labs.

Despite the handicap several HICLs survived and even thrived. The cost of medical testing, however, was soaring. In an attempt to rein in costs the province introduced limits on the private lab corporations. In exchange for this concession the government agreed to phase out the HICLs—clearing another competitor from the marketplace. The private labs argued that they employed 15,000 people and that these jobs had to be protected.

Sutherland argues that the Mike Harris government caved into the powerful lobby—in effect killing a much lower cost system of blood and specimen collection and testing.

Currently the province spends more than $600 million on lab testing services to private corporations. It is the highest penetration of private companies in the lab business in Canada.

Sutherland warns the labs experience in Ontario provides a useful caution against further integration of private service providers into the single payer health system we use in this country.

“It’s a slippery slope,” said Sutherland. “Once the door is opened it becomes very difficult to close it again.”